Which physiological change should a nurse expect to observe when assessing an elderly client?

Place the call bell in reach and respond promptly when activated.

This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.

Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.

The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.

Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.

The bed should be lowered to a safe position and locked when not in use.

Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.

The client should have adequate lighting in their room and be oriented to their surroundings.

Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.

Face the client while speaking and ask them to verify understanding. This intervention would help the client to read the nurse’s lips and confirm the message.

It would also show respect and empathy for the client’s condition.

Choice A is wrong because using exaggerated mouth and hand movements when speaking can be distracting and insulting to the client.

It can also distort the words and make them harder to understand.

Choice C is wrong because standing in front of a light when speaking to the client can create glare and make it difficult for the client to see the nurse’s face.

Touching the client to be sure they know where you are can be startling and unnecessary if the client is not visually impaired.

Choice D is wrong because obtaining an interpreter for sign language is inappropriate unless the client knows sign language.

Not all hearing-impaired clients use sign language, and some may prefer other methods of communication.